REPUBLIC OF THE PHILIPPINES )

City of___________ ) S.S

x-------------------------x

AFFIDAVIT OF LOSS

I, JUAN DELA CRUZ, of legal age, Filipino, single, and a resident of ADDRESS,
Philippines after having been duly sworn in accordance with law, hereby depose and say that:

1. I am a regular user of a Smart Mobile Subscriber Identity Module (SIM) Card with No.
739849834927492 since the year 2020;

2. On the morning of November 21, 2022, when I left my workplace at PLACE OF WORK
on-board my motorcycle, I placed inside the pocket of my pants, my cellular phone where
the said SIM Card is inserted;

3. When I made a stop at PLACE, I noticed that my cellular phone was no longer inside my
pocket so I went back and retraced the path I took;

4. I failed to find and recover my cellular phone and the said SIM Card despite diligent
search and earnest efforts to contact and locate the said phone, and I consider the same as
lost and can no longer be found;

5. I am executing this Affidavit to attest to the truth of the foregoing facts and in support of
my application for the replacement of the said SIM Card and for whatever legal intents
and purpose it may serve.

IN WITNESS WHEREOF, I have hereunto affixed my signature this 24 th day of

November 2023 in NAME OF CITY, Philippines.

Affiant
Driver’s License No. ____

SUBSCRIBED AND SWORN TO before me this 24th day of November 2023 in NAME
OF CITY OR PROVINCE, Philippines, affiant exhibited his Driver’s License No.
347290745982572 bearing the affiant’s photograph and signature, thru which his identity was
confirmed.

Doc No. _______;

Page No. _______;
Book No. ______;
Series of 2022